Physician Services Modifiers Explained
and
New “Distinct Procedure” Modifiers
Overview
Mission of G2N
We work to ensure America’s healthcare
providers have honest & healthy bottom lines
in order to continue to fulfill their mission of
Rosie Donovan, RHIA, CCS-P
Rosie is a Client Partner for G2N, Inc. Rosie provides coding, documentation & acquisition audits and other revenue cycle consulting services.
Rosie Donovan, RHIA, CCS-P
• 25+ years of physician practice experience in both multispecialty, independent and Rural Health Clinic ambulatory medical groups
• Focus on documentation and coding audits, compliance, acquisition audits and reimbursement
• B.S. from Saint Louis University
• RHIA, CCS-P credentialed by AHIMA
• AHIMA-Approved ICD-10-CM/PCS Trainer • Joined G2N in 2004
Disclaimer
• The examples and discussion are not meant
to be used as coding advice.
• This presentation will discuss AMA/CPT and
Medicare use of modifiers. Check with your
other third party payers for modifier policies.
• This session is for physician and
non-physician modifiers, therefore Hospital,
Facility and/or ASC modifiers will not be
discussed.
Agenda
Review typical Modifiers used by Health Care Providers Review definitions & requirements & example cases
Review new “Distinct Procedure Modifiers” Questions
NOTE: all data contained herein is valid as of January 2015. CMS is continually changing billing and coding rules. Please check with your MAC for the most up to date guidelines.
Billing & Documentation Guidelines
Coding and documentation are not the top priority of
practitioners (nor should they be)
Our goal is to help practitioners understand modifier use
and documentation requirements so that they can be
used appropriately
We follow CPT rules, which apply to all carriers & all
practitioners
Documentation
“…if it is not documented, it did not happen”
“…if it is not documented, it is not billable”
Documentation must reflect the service(s) and the
reasons for the service(s) billed.
Know and understand the documentation
requirements for the types of services you provide.
E&M, Diagnostics, Procedures
Healthcare and Reimbursement
Nuances of reimbursement are complex
Regulations are constantly changing
Physicians don’t have time to keep up with the
status quo of coding compliance
Basics of Coding & Documentation
Document
what
was done
Document
why
it was done
Modifier Definition
What is a modifier?
• Modifiers are used to add information or change the
description of service in order to improve accuracy
or specificity.
– Two (2) digits – alpha/ alphanumeric/ numeric.
– Attaches to CPT and/or HCPCS Level II code.
• Procedure codes are “modified” under certain
circumstances to more accurately represent the
service or item rendered.
Modifiers Use
• Modifiers are used by both hospitals and physicians.
• Modifiers affect and are affected by the surgical global
period.
• The time frame in the global period is not the same for
hospitals and physicians.
• For Hospitals, the global period does not apply.
• For Physicians, the global period is 0, 10, or 90 days
(payer policies may vary)
• There are different modifiers for the same/similar
situation
.
Modifiers & Third Party Payers
• Providers should follow third party payer
guidelines when it comes to modifier
assignment.
• While the definitions of the modifiers
themselves will not change, the use of the
modifier may.
Example: MO Medicaid does not recognize
Modifier 57- Decision for Surgery
.
Where to find? How to use?
• Refer to CPT book – Appendix A
• Refer to your J MAC- Part B Carrier
• Neither is a comprehensive list of modifiers
• Per Claim form - 4 modifiers allowed per code
• Formats are different depending on the
modifier and the payer
• Review Medicare and other third party payer
policies for information and reporting
Medicare & Modifiers
• Use MPFS to determine some modifiers use
• Payment or pricing modifier(s) always in 1
stposition on claim form.
– E.g. 50 modifier or bilateral procedure
• Hierarchy for payment modifiers on which
goes first when multiple modifiers
– Check your local J MAC list- Ask when in doubt!
• Informational modifier(s) always placed after
pricing modifier.
Modifier Look Up – Using MPFS
See resource MPFS Look Up
• You will need 3 links:
1)
http://www.cms.gov/apps/physician-fee-schedule/overview.aspx2)
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-
Network-MLN/MLNProducts/downloads/How_to_MPFS_Booklet_ICN901344.pdf
-see page 10- of this document for example Payment Policy Indicators
3)
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/PhysicianFeeSched/PFS-Relative-Value-Files-Items/RVU15A.html?DLPage=1&DLSort=0&DLSortDir=descending
Example - 47480
STATUS PCTC GLOB PRE INTRA POST MULT BILAT ASST CO-HCPCS DESCRIPTION CODE IND DAYS OP OP OP PROC SURG SURG SURG
47480 gallbladderIncision of A 0 090 0.09 0.81 0.10 2 0 2 1
Status code- A means active code
PC/TC IND- 0 means this concept does not apply since this
procedure cannot be split into technical (TC) and professional (PC) components
GLOB DAYS- 090 means this procedure has a 90 day global period
MULT PROC- 2 means standard payment adjustment rules for Multiple procedures apply. E.g. if this procedure is 1st listed Payment is 100%. If
listed 2nd with 51 modifier than payment is 50%.
BILAT SURG- 0 means 150% payment adjustment does not apply And so on…
Modifier Meanings
Separate sessions
• 58, 78, 79, 59- Now “X” modifiers
Separately identifiable services
• 25, 57, 59- Now “X” modifiers Reduced/Discontinued • 52, 53 Multiple • 51, 99 Repeat • 76, 77
Modifier Meanings
Role in surgery • >1surgeon: 62, 66 Assist Surgeon: 80, 81, 82, AS Split care or splitting the global surgical package
• 54, 55, 56
Decision for surgery
• 25, 57
Unusual
Site Specific Modifiers
Coronary artery
• LC-Left Circumflex
• LD-Left Anterior Descending
• RC-Right Coronary Artery
-Only valid on certain CPT codes
Eyelids
• E1 -Upper left
• E2 -Lower left
• E3 -Upper right
• E4 -Lower right
Site Specific Modifiers
Separate site
• Coronary Arteries, Fingers and Toes, 59- Now
“X” modifiers
Left/Right
• LT- Left side
• RT- Right side
Bilateral
• 50
Modifiers, when do we use?
• When should a modifier be used?
– If the answer is yes to any of the following
questions, then it is appropriate to use the
applicable modifier.
• Would the modifier add more information regarding the anatomic site of the procedure?
• Would the modifier help eliminate the appearance of duplicate billing?
• Would a modifier help eliminate the appearance of unbundling?
Modifier 24
Unrelated E&M service by the same physician during a postoperative period.
– Inpatient hospital care furnished during the same hospitalization as the surgery is not payable unless the physician is also treating
another medical condition unrelated to the surgery.
– Used to indicate an unrelated E&M service was provided during the post operative period.
Unrelated?
- Different diagnosis
- Same diagnosis, but treating the underlying condition, NOT complications from surgery or normal recovery.
- Patient note should reflect the management of a new problem or the underlying condition that prompted the surgery.
Modifier 24 - Example
An excision of a malignant lesion from the right thigh is
performed in the office on January 10, 2015. The diagnosis code reported is 171.3 (Malignant neoplasm-soft tissue of thigh). The procedure has a 10 day post-operative period.
The patient returns to the office on January 15, 2014 and is treated for contact dermatitis – diagnosis code 692.9. The
physician should report the appropriate E&M code followed by modifier 24.
Modifier 25
Significant, separately identifiable E&M service by the same physician or other qualified health care
professional on the same day of a procedure or other service.
– Used with MINOR procedures (0 or 10 global days). – Different diagnosis code is not needed.
– Documentation supports E&M above & beyond that which is required for pre/post procedure evaluation.
– Patient care note should clearly reflect the work and management of physician beyond that of the pre/post procedure evaluation.
Minor Procedures & Modifier 25
• Global period of 000 or 010 days, it is defined as a
minor surgical procedure.
• In general, E&M service on the same date of
service as a minor procedure is included in the
payment for the procedure.
• However, a significant and separately identifiable
E&M service unrelated to the decision to perform
the minor surgical procedure is separately
reportable with modifier 25
.
• Some NCCI edits exist but not for all possible
scenarios.
Modifier 25 - Example
1) Diagnostic procedures- necessary because
exam is inadequate- E.g. Otoscope-Exam &
Nasal Endoscopy
2) Therapeutic procedure- necessary because
exam indicates evaluation of system unrelated
to decision to perform procedure- lesion
removal-neck, exam of lymphatic and
neurologic
Modifier 25 Use
• Modifier 25 – Questions to ask yourself.
– What was the purpose of the patient’s visit?
– Is there anything that would prompt a separate E&M service?
– Does the documentation support an E&M service over and above the usual work for the procedure?
In 2003, the OIG reported overpayments in
excess of $538 Million due to the inappropriate
use of modifier 25.
Modifier 25 - Example
A physician examines a patient complaining of a
headache, vomiting, fever, and stiff neck. The
physician performs the services described in code
99214 providing a detailed exam of the following
Constitutional/GI/Neurological/Neck, as well as a
spinal puncture using code 62270.
Is it appropriate for the physician to report this patient
encounter with codes 62270 and 99214-25?
Yes, modifier 25 is appropriate, because evaluation of
complaint is greater than evaluation pre/post 62270.
Polling Question #1
Have you found that some of your
Third Party Payers are also requiring
the use of Modifier 25 when an E&M
and a diagnostic procedure (Chest
x-ray, EKG, etc.) is performed on the
same day?
a. Yes
b. No
Modifier 57
Decision for Surgery
– Indicates an E&M service resulted in the initial
decision to perform surgery either the day before
a major surgery (90 day global) or the day of a
major surgery.
– Cannot be used with a minor surgery (0 or 10 day
global).
– Appended to the E&M service to denote the visit
where the decision to perform the surgery was
made.
Modifier 57 - Example
A patient with abdominal pain is referred to a Surgeon to determine if surgery is necessary. The requesting physician agrees with the findings of the Surgeon and requests the
Surgeon assume care and discuss his findings with the patient. The patient undergoes surgery later that day by the Surgeon. Is it appropriate to report the Surgeon’s E&M service with
modifier 57 indicating the consultation is not part of the global surgical procedure in addition to reporting the appropriate code for the specific surgical procedure?
Yes, Surgeon made the decision to perform the surgery on the patient the same day as the surgery.
Modifier AI
Principal Physician of Record
• Identifies the admitting or attending physician who oversees patient care while in an inpatient or nursing facility setting.
• Appended to the initial inpatient hospital visit E&M code or the initial nursing facility E&M code.
– Should not be used by physicians providing
specialty care. If not admitting don’t use!
– Does not affect payment. Informational modifier.
– Append to initial E&M services of admitting
Modifiers Used on Surgical &
Diagnostic Services
Global Surgical Package
Global Surgical Package
Surgical
CPT Code
Preoperative
Period
Intraoperative
Time
Postoperative
Global Period
Incision and
Approach
Resection or
Repair
Closure
Global Surgical Package
CPT Says Medicare Says
Pre-op Period
Subsequent to the decision for surgery, one related E&M encounter on the date
immediately prior to or on the date of procedure (including history and physical)
E&M in which the decision is made is separately billable. Visits to perform history and physicals are not separately reportable.
Major procedure has a preoperative global period
of day before and day of the procedure
Minor procedure has a preoperative global period
of the day of the procedure
Intra-op Service
Local infiltration, metacarpal/ metatarsal/digital block or topical anesthesia. Moderate (conscious) sedation may be reported
in CPT
Immediate postoperative care, including dictating operative notes, talking with the family and other physicians
Writing orders
Evaluating the patient in the post- anesthesia recovery area
Pain management services
Intraoperative nerve monitoring by the surgeon
Anesthesia of any kind given by the operating surgeon. Exception: moderate (conscious) sedation may be reported by the surgeon when appropriate.
Discussion with patient/family about the nature of the procedure, alternative treatment risks, benefits and other informed consent issues
Scheduling surgery
Writing preoperative admission notes and orders Dictating the operative record
Writing postoperative orders and postoperative prescribed care
Postoperative pain management including catheter placement by operating surgeon Intraoperative nerve monitoring by the surgeon
Post-op Period
Typical follow-up care Follow-up care including treatment of
complications unless they require a return to the
operating room for the prescribed follow-up period
Major procedure has a postoperative global period
of 90 days
Minor procedure has a postoperative global period
E&M and Surgical Global Days
Remember: During 0-, 10-, and 90-day global
periods, you shouldn’t separately bill E&M
services that are part of the normal pre-op,
surgical, or post-op care.
That includes any E&M service provided during
the post-operative period that is related to the
recovery from the surgery, including pain
CMS – CPM, Sec 40, Ch 12
Section 40.1 of the Claims Processing Manual (Pub. 100-04, Chapter 12
Physician/Nonphysician Practitioners) defines the global surgical package to include the following services when furnished during the global period:
• Preoperative Visits—Preoperative visits after the decision is made to operate beginning with the day before the day of surgery for major procedures and the day of surgery for minor procedures;
• Intra-operative Services—Intra-operative services that are normally a usual and necessary part of a surgical procedure;
• Complications Following Surgery—All additional medical or surgical services required of the surgeon during the postoperative period of the surgery because of complications that do not require additional trips to the operating room;
• Postoperative Visits—Follow-up visits during the postoperative period of the surgery that are related to recovery from the surgery;
• Postsurgical Pain Management—By the surgeon;
• Supplies—Except for those identified as exclusions; and
• Miscellaneous Services—Items such as dressing changes; local incisional care; removal of operative pack; removal of cutaneous sutures and staples, lines, wires, tubes, drains,
casts, and splints; insertion, irrigation and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy
Modifier 22
Increased Procedural Service requiring work substantially greater than typically required.
– Used on surgeries where services performed are significantly greater than usual
• Anatomical variants, increased intensity, technical difficulty, severity of patient’s condition, extra time, etc.
– Additional time alone does not justify the usage of this modifier. – Do not use when there is an existing code to describe the service. – Requires explanation in comment field on claim submission and/or
the operative report and a separate statement indicating how the service differs from the usual.
– Reimbursement: no set amount for fee increase (+25%). – Append to appropriate CPT code.
Modifier 22 - Example
Emergent appendectomy took an hour and a
half longer due to dense adhesiolysis.
Laparoscopic Appendectomy + 1 ½ hours of
additional work due to adhesions.
Modifier 50
Bilateral Procedure
• Unless otherwise identified in the CPT code
description, bilateral procedures performed at the
same operative session should be identified by adding modifier 50 to the appropriate CPT code.
• Must be performed on a paired part of the body, not simply left and right side.
• Skin does not have a left and right side.
• Reimbursement usually calculated at 150% of allowable.
Modifier 50 Use
• Check with 3
rdparty payers for billing
preferences
-a single unit of service and modifier 50
-one unit on each line using modifier
RT/LT
-two units of service on a single line and
no modifier
• Payer policies apply here. Verify policy before
coding/billing.
CMS and Modifier 50
• CMS reminds providers to report bilateral
surgical procedures on a single claim line
with modifier 50 and one (1) unit of service.
When modifier -50 is required by manual or
coding instructions, claims submitted with two
lines or two units and anatomic modifiers will
be denied for incorrect coding.
• Review MPFS to determine if bilateral
(modifier 50) is allowed.
Modifier 51
Multiple Procedures performed on the same
day, during the same surgical session.
– Do not use on:
• “Add on” codes.
+
sign in front of the code. See Appendix D in CPT code book.• “51 exempt” codes. sign in front of code. See Appendix E in CPT code book.
– Modifier 51 is to be assigned to the code(s) with
lower RVU values when multiple codes are billed.
– Reimbursement usually indicates fee reduction
Modifier 51- Example
Surgeon performs an adenoidectomy and
placed a tympanostomy tube at the same
operative session.
Adenoidectomy – 42830 (RVU 6.02)
Tympanostomy – 69436-51 (RVU 4.63)
Code with 51 modifier expect 50% payment
reduction.
Modifier 52
Reduced Service
- Reports a reduced or partially eliminated service or procedure at the physician’s discretion.
– When the procedure was completed but a portion is not performed.
– Bilateral procedures performed on one side. – Do not use for terminated procedures.
– Do not use for situations when the patient has the inability to pay the full charge.
– Do not use on a time based code (i.e. anesthesia, psychotherapy, or critical care).
Modifier 52 - Example
A patient with a history of Breast Ca. is seen with complaint of lump on arm. Ultrasound of lump is inconclusive. Surgeon performs incision and dissects down beneath subcutaneous tissue – no mass found.
Report CPT code 24075-52.
A Therapeutic Colonoscopy is performed but the scope cannot be moved beyond the splenic flexure and therefore the scope is reduced due to no visualization of the cecum.
Modifier 52 – Inappropriate Use
Do Not Use!
If the planned radiological service is a two-view
chest x-ray and only one view of the chest is
performed,
Do not report CPT code 71020-52 (for x-ray
chest, two views-reduced service).
Report CPT code 71010 (x-ray chest, single
view).
Modifier 53
Discontinued Procedure
– The procedure was started but was discontinued
before completion due to patient’s condition or
extenuating circumstances.
• Discontinued procedure after induction of anesthesia. • Do not use on time based procedure codes. (i.e.
critical care and psychotherapy)
• Do not report on discontinued surgeries prior to the induction of anesthesia.
• Reimbursement no set fee reduction.
Modifier 53 - Example
Midway through a thyroidectomy, the patient’s
blood pressure severely drops. Anesthesiologist
advises discontinuing the surgery.
Thyroidectomy – 60240-53
Diagnoses:
1
st- Procedure not carried out due to
contraindication: V64.1
2
nd- Iatrogenic Hypotension: 458.2
3
rd- Goiter, unspecified: 240.9
Modifier 54 & 55
Split Surgical Package
- These modifiers indicate the Surgeon is not
providing the entire surgical package and is
“splitting” the post operative care with
another Provider.
• Modifier 54 is used by Surgeon.
• Modifier 55 is used by other Provider who is
providing all or part of Post-Operative Care.
Modifier 54 & 55 Use
Both claim forms must match exactly in regards
to the surgical CPT code. This would be on the
first line of the claim form.
Each must have:
- same surgical date
- same surgical CPT code
- different Place Of Service
- # of units = 1
Modifier 58
Staged or related procedure or service by the
same physician during the postoperative
period.
• Used for a procedure the physician performs during the postoperative period if the procedure is:
– Planned or anticipated (staged)
– More extensive than the original procedure
– For therapy following a diagnostic surgical procedure
– A new postoperative period begins
– Reimbursement no fee reduction
Modifier 58 - Example
The physician performed a D & C on May 1 and
then performed a hysterectomy on May 9.
Report 58120, 10 day global begins on May 1.
Report 58210-58, 90 day global begins on May
8.
- You do not need to bill both procedures on the
same claim form. However if you do it is
Polling Question #2
When using these procedure modifiers
do you change your fee on the claim?
a. Yes
b. No
Modifier 59
Distinct Procedural Service
• Identifies procedures/services not normally reported together, but appropriately billable under the
circumstances.
– Documentation indicates two separate procedures performed on the same day by the same physician
• Represented by a different session or patient encounter, different procedure or surgery, different site, or separate injury (or area of injury)
– Modifier of last resort.
– Bypasses NCCI (National Correct Coding Initiative) edits. – Often used instead of billing units.
Modifier 59
• Most widely used and sometimes abused modifier • Can be broadly applied
• Some Providers incorrectly consider it to be the “modifier to use to bypass (NCCI) edits”
• *Abuse and high utilization have created increased audit activity; leading to reviews, appeals and even civil fraud and abuse cases.
• Primary issue is that it is defined for use in a wide variety of circumstances, such as to identify:
– Different encounters;
– Different anatomic sites; and – Distinct services.
*In 2003, the OIG reported overpayments in excess of $59 Million due to the inappropriate use of modifier 59.
*More recently, 2013 CERT Report data projected a one-year error of $770 Million in incorrect modifier 59 payments
X {EPSU} Modifiers
Effective January 1, 2015- CMS debuts 4 new “distinct procedure”
modifiers to substitute for the 59 in specific circumstances, they are:
• XE – Separate Encounter: a service that is distinct because it occurred during a separate encounter
• XP – Separate Practitioner: a service that is distinct because it was performed by a different practitioner
• XS – Separate Structure: a service that is distinct because it was performed on a separate organ/structure
• XU – Unusual Non-Overlapping Service: the use of a service that is distinct because it does not overlap usual components of the main service
When is modifier 59 used?
The National Correct Coding Initiative (NCCI)
• Created Procedure to Procedure Edits
• Developed by CMS
• Promote correct coding methodologies
• Eliminate improper coding
• Edits are based on coding conventions, current
coding practice and input from societies and
analysis of current coding practices
• Edits are created to help prevent the unbundling of
procedures and services in various settings.
PTP Edits
Procedure to Procedure (PTP) edits indicate that the
second code in the code pair is considered bundled
into the work involved in the first code.
– Column 1 – comprehensive code - payable
– Column 2 – component code – not payable
• The “component” code can become payable if the
edit indicator allows it, and documentation supports
Edit Indicators
CCI Edit Indicators:
• 0 – modifier does not apply
– Never unbundle a code pair that has a 0 indicator
• 1 – modifier does apply
– Use modifier on component code if supported
• 9 – not applicable- edit was deleted
See: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1418.pdf
Edit indicator “1”, but which modifier?
NCCI instructions:
“All other modifiers should be evaluated for
possible application prior to the use of modifier
59 or the new X-EPSU modifiers.”
• Use modifiers such as RT/LT, finger, toe or
eyelid modifiers in addition to sometimes
utilizing Modifier 25 prior to the use of these
new modifiers.
XE - Example
Patient is seen in the outpatient infusion center
at 8:00 a.m. and seen again in the outpatient
infusion center for an IM injection at 6:00 p.m.
-Separate encounter = XE
96365 (column 1/NCCI =1)- antibiotic
intravenous infusion
96372-XE (column 2/NCCI =1)- antibiotic
intramuscular injection- performed at a
XP - Example
Patient undergoes a hernia repair by Dr. Smith at 7:00
a.m. Later in the day the patient develops acute
abdominal pain and returns for another physician to
perform a surgical laparoscopic appendectomy by Dr.
Jones. Both doctors are part of the same general
surgery group.
- Separate Practitioner - XP
- 49650 (column 1 /NCCI=1)- Laparoscopic hernia
repair
- 44970-XP (column 2 /NCCI=1)-Laparoscopic
XS - Example
Physician destroys an actinic keratosis on the
hand and removes a melanocytic nevus from the
ear.
-Separate anatomic sites - XS
17000 (column 1 /NCCI=1 )- Destruction
premalignant lesion; first lesion (hand).
11440-XS (column 2 /NCCI=1 )- Excision, benign
lesion including margins, ear: excised diameter 0.5
or less performed on a separate site!
XU - Example
A patient presents to the ED with a fall at home
due to dehydration. ED Physician performs an
intermediate repair of scalp and orders an infusion
due to the dehydration.
-Non-overlapping service – XU
12031 (column 1/NCCI=1)- Repair, intermediate,
wounds of scalp; 2.5 cm or less
96365-XU (column 2/NCCI=1)- Therapeutic
intravenous infusion; initial, up to 1 hour performed
as a non-overlapping service
.
Available Guidance?
WE NEED MORE GUIDANCE!
• Contact NCCI and CMS via the email
address given in SE1503.
• Submit specific questions and examples
about how to use the new modifiers.
• Hopefully this may facilitate the release of
more guidance.
Can we use 59 Modifier?
• YES - modifier 59 is still available for use!
• My local carrier (WPS) is not requiring providers to use any specific modifier.
• Remember: when evaluating a coding pair listed as part of the National Correct Coding Initiative (NCCI), the column 2 procedure code is not payable unless the medical record documentation and specific
circumstances show the service is a distinct and separate service as described in the NCCI manuals.
• Providers should evaluate the use of other modifiers including the new -X {EPSU} prior to using modifier 59.
SE1503-MLN Matters – Continued Use of modifier 59 after January 1, 2015.
Do Not Use!
• Code pair does not create an PTP edit.
• Same procedure/CPT code was performed
multiple times.
(Not a “repeat procedure”)• CPT code allows billing in multiples or units.
– Bill CPT code on one line with multiple units. Example: .5 cm benign lesions were removed
from cheek and forehead.
11440 x 2 units –excision benign lesion,
Polling Question #3
Have you received a rejection when
using the new X-EPSU modifiers?
a. Yes
b. No
Modifier 76
Repeat Procedure by the Same Physician
• Used when it is necessary to report repeat procedures performed on the same day by same Physician.
• This modifier should not be added to procedures
designated as “add on” codes. These are identified in the CPT book by a plus (+) sign in front of the code.
– Medicare considers two physicians in the same
group with the same specialty performing
services on the same day as the same physician.
– Do not confuse with billing units or multiples.
76 - Example
Tonsillectomy performed on January 15
th.
Patient returned to OR on January 16
thfor
control of 1
stpost-op tonsil bleed. Later in the
afternoon patient is returned to OR on same
day for 2
ndpost-op tonsil bleed.
42962-78 Control oropharyngeal hemorrhage
(return to OR- related)
42962-76 Control oropharyngeal hemorrhage
(repeat procedure on same day)
Modifier 77
Repeat procedure or service by another physician or other
qualified health care professional
• Append to the professional component of an X-Ray or EKG procedure when a different physician repeated the reading as the physician performing the initial
interpretation believes another physician's expertise is needed.
• Append to the professional component of an X-Ray or EKG procedure when the patient has two or more tests and more than one physician provides the
interpretation and report.
Modifier 78
Unplanned return to the operating room by the same physician following initial procedure for a related
procedure during the postoperative period.
• To identify a related procedure (that has a 000, 010, 090, YYY, or ZZZ global surgery indicator) requiring a return trip to the
operating room (OR) on the same day as or within the postoperative period of a major or minor surgery.
• To treat the patient for complications resulting from the original surgery.
• When the procedure code used to describe a service for
treatment of complications is the same as the procedure code used in the original procedure, modifier 78 is still the correct modifier to use.
Modifier 78
Modifier 78 – Questions to ask yourself.
– Does the procedure fall within a global period?
– Is the procedure “related” to or complication of
the initial surgery?
– Is there a return to the OR?
If yes is the answer to all three questions, it is
appropriate to use Modifier 78.
•
A new global period does not begin.
Modifier 79
Unrelated procedure by the same physician
during the post-operative period
• To describe an unrelated procedure performed during the post-operative period of the original procedure. • The two procedures are performed by the same
physician.
• All procedure codes except those with XXX in the GLOB (global) field of the MPFS data base.
• A new global period will begin. • Reimbursement reduction apply.
Modifier 80
Assistant at Surgery
– Use Modifier AS if the services are provided by a
physician assistant (PA) or nurse practitioner
(NP) or clinical nurse specialist (CNS).
– Use Modifier 80 if the services are provided by a
medical doctor (MD/DO).
– Operative note by Surgeon must support what
services assistant provided.
Modifier 62
Co-Surgery, or Two Surgeons
• Under certain circumstances the skills of two surgeons (must be different subspecialists) may be required in the management of a specific surgical procedure.
Under such circumstances the separate services may be identified by adding the modifier 62 to the
procedure code.
• Both surgeons need to report the same surgery code with the modifier 62.
• Each surgeon should have their own operative note describing what specifically they did.
Anatomic Modifiers
LT – Left side
RT – Right side
• Identifies procedures that can be performed on
paired body parts or organs such as lungs and
kidneys.
• DO NOT use when modifier 50 applies or
Anatomic Modifiers
Modifiers are available to indicate procedures
performed on fingers and toes.
F1 left hand, second digit T1 left foot, second toe F2 left hand, third digit T2 left foot, third toe F3 left hand, fourth digit T3 left foot, fourth toe F4 left hand, fifth digit T4 left foot, fifth toe F5 right hand, thumb T5 right foot, great toe F6 right hand, second digit T6 right foot, second toe F7 right hand, third digit T7 right foot, third toe F8 right hand, fourth digit T8 right foot, fourth toe F9 right hand, fifth digit T9 right foot, fifth toe FA left hand, thumb TA left foot, great toe
Modifier QW
CLIA-waived test
– Laboratory testing site has CLIA certification to
perform certain tests.
– Submit this modifier with clinical laboratory tests
that are waived from the Clinical Laboratory
Improvement Amendments of 1988 (CLIA) list.
– The Food and Drug Administration (FDA)
determines which laboratory tests are waived.
– CLIA certification number is required on claim.
http://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/downloads/waivetbl.pdf
Modifier Q6
Services furnished by a Locum Tenens Physician
– When a physician agrees to see patients of anotherphysician under arrangements of the original physician. – The regular physician is not available to see patients. – The patient arranges or seeks service of their regular
physician.
– Short term coverage provided, under 60 days.
– The physician seeing the patient is not in practice for themselves, or employed as part of another practice.
Modifier TC
Diagnostic Services
TC – Technical Component
– Identifies the technical component of certain
services that combine both the professional and
technical portions in one procedure code.
• To bill for only the technical component of a test. • When billing both the professional and technical
component of a procedure when the technical
component was purchased from an outside entity, the provider would bill the professional on one line of
Modifier 26
Diagnostic Services
26 – Professional Component
– Refers to certain procedures that are a
combination of a professional component and a
technical component.
• To bill for only the professional component of a
test.
• To report the physician’s interpretation of a
test.
Modifiers Used on Unlisted CPTs
Unlisted CPT codes
– DO NOT append modifiers to unlisted CPT
codes.
• Unlisted CPT codes do not have descriptions,
therefore they cannot be modified.
• A modifier cannot tell why the unlisted CPT
code was altered.
Resources
• NCCI – Policy Manual
http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html?redirect= /NationalCorrectCodInitEd
• WPS Modifiers
http://wpsmedicare.com/j5macpartb/resources/modifiers/
• CLIA Waved Test List
http://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/downloads//waivetbl.pdf
• CMS Claims Processing Manual – Ch.12, Sec 40
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf
• CMS Claims Processing Manual – Ch.23, Sec 20.3
“A reality of medicine is that it doesn’t matter how smart you are or how brilliant your diagnosis; you don’t get paid any more money for these things. In
medicine, you get paid for how much [how
effectively] you can document.”